Homeowners Quote Request

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Homeowners /Renters /Manufactured Home (Mobil)/ Flood Insurance Quote Request

Please fill out as much information as possible.

If you have any questions regarding this form please contact us.

Home Quote Request Form - (Texas Residents Only!)

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

First Named Insured:

Additional Named Insured ( Usually Spouse):

*Full Name (as shown on your drivers license):

Full Name (as shown on your drivers license):

*SSN #

*DOB:

SSN #

DOB:

(ie;999-99-9999)

(MM/DD/YYYY)

(ie;999-99-9999)

(MM/DD/YYYY)

*Business/Industry :

*Occupation

If "Other" Occupation Please Describe

*Highest Level of Education

Business/Industry : Occupation

If "Other" Occupation Please Describe

Highest Level of Education

Email Address: (For Our Agency Staff Use Only)

*Email Address : (For Our Agency Staff Use Only )

Fax #

*Send Quick Quote By : Email Fax Both

*Contact Phone Numbers:

Day :

Evening :

Cell :

Do you currently have Homeowners Insurance? Yes No

*If yes, Name of Current Carrier:

*Policy #

*Expiration Date:

* Prior Annual Premium * Current Renewal Premium

If yes, how long have you had Homeowners Insurance with your current insurer?

If no current coverage how long has it been since you had homeowners insurance?

Year you purchased home? Initial Purchase Amount $

Physical Address:

*Address:

*City:

*State: Zip:

*County :

Mailing Address: Same as Mailing Address
Address:

City:

State : Zip:

County:

Coverage Policy Limits Requested :

*Type of Dwelling To Be Insured :		*Requested Effective Date:
*Deductible:		*Wind/Hail Deductible:
*Dwelling Coverage $		*Personal Property Coverage $
*Personal Liability Limit $		*Medical Payments Limit $

*Sewer/Drain Back-Up Limit $

*Sudden Accidental Water Discharge/Leakage Damage Limit $

*Replacement Cost Coverage

Dwelling

Personal Property

Optional Coverages

Most Commonly Requested

Glass Mold Scheduled Jewelry $ Scheduled Silverware $ Special Computer $ Collections: Art/Stamps/Guns/Other $ Increased Adjacent Structures $ Ordinance Of Law Unscheduled Home Business Property $ Small Outboard Motor Liability $

Policy Form Requested :

*Please Select The Standard Texas Homeowners Coverage Form(s) You Wish Us To Provide A Quote For :

HO-A ( Named Perils Policy Forms - typically offers lower rates in exchange for coverage that only pays when a loss caused by a named perils/risk listed in policy occurs ) ** This Policy Form Generally Offers The Lowest Possible Rates In Exchange For More Limited Coverage.

HO-B ( Broad Policy Forms - typically offers moderate rates in exchange for coverage broader form with all risk coverage on dwelling and broad form named perils/risks coverage available for personal property ) *** This Policy Form Is Our Most Often Selected "Top Choice" By Our Customer As It Offers A Great Value (Benefits VS Cost) .

HO-C ( All Risk Policy Forms - typically offers higher rates in exchange for the extensive coverage available by providing all perils/risk coverage for losses that occurs which are not specifically excluded perils/risks or otherwise specifically limited within the policy form. ) ** This Policy Form Is Normally Selected By Homeowners With Higher Than Average Valued Homes Who Are Seeking The Most Extensive Homeowners Coverage Available To Protect Many Of Their Most Valuable Personal Assets "

All Of The Above ( I wish to compare all three Standard Texas Homeowners Coverage Forms )

* Do You Want Us To Also Provide You With A Flood Insurance Quote ? Yes

* Do You Want Us To Also Provide You With A Personal Umbrella Liability Policy ? Yes

Check Here If You Are Requesting Quote For " Renters Personal Property Insurance Policy "

Underwriting Information:

*Construction:		*Roof:		*Roof Age:		*Square. Footage:
*Year Built:		*Stories:		*Garage:		*# of Car Stalls:
*Occupancy:		*Pool:		*Fenced Pool :		*Trampoline:
*Pets:		(Pets) Breed:		*Alarms:		*Monitored:
*Fire Hydrant Feet To	0-100 101-500 501-1000 1000+	*Fire Station	Miles Within 5 5 -10 10+	*Within City Limits	Yes No	*Primary Residence	Yes No
*Foundation		*Rental Property	Yes No	*Community Entrance Gated or Guarded	Yes No	Sprinkler System	Yes No
*Under Construction	Yes No	*Live Stock	Yes No	*Strom Shutters	Yes No	*Mortgagee	Yes No
*Owner Occupied	Yes No	*Maintenance		*Air Conditioning Ducts		*Farm Home	Yes No
*Fire Place	Yes N	*Wood Burning Stove	Yes N	*Central Air Conditioning Heating	Yes	*Dead Bolt Smoke Alarm Extinguishers	Yes No
*Any losses incurred in the last 5 years to the insured's home or personal possessions at this or another location? Yes No If "Yes" Please Provide Details:
*Has property insurance been cancelled, declined or non-renewed in the last 5 years? Yes No If "Yes" Please indicate reason property insurance was cancelled, declined or non-renewed?
Is dwelling unoccupied by owner for more than 8 consecutive weeks per year ? Yes No

If the home is over 20 years old, please indicate the year updates were completed:

Electrical	Roof	Plumbing	Heating

Comments/Remarks:

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage.

To confirm binding or current policy revisions you must receive a written confirmation for any new or change in coverage from our agency staff.

Is there a Co-Applicant?				Yes No
Co-Applicant Information
Co-Applicant First Name
Co-Applicant Middle Name
Co-Applicant Last Name
Co-Applicant Social Security Number
Co-Applicant Social Security Number Status
Co-Applicant Relationship to Insured
Co-Applicant Date of Birth

Co-Applicant Gender

Co-Applicant Marital Status

Co-Applicant Business/Industry

Co-Applicant Business (if "Other")
Co-Applicant Occupation

Co-Applicant Occupation (if "Other")
Co-Applicant Highest Level of Education

Spouse Information
Spouse First Name
Spouse Middle Name
Spouse Last Name
Spouse Social Security Number
Spouse Social Security Number Status
Spouse Date of Birth
Spouse Gender
Spouse Marital Status
Spouse Business/Industry
Spouse Business (if "Other")
Spouse Occupation
Spouse Occupation (if "Other")
Spouse Highest Level of Education
Spouse First Name
Spouse Middle Name
Spouse Last Name
Spouse Social Security Number
Spouse Date of Birth
Spouse Gender				Select One
Spouse Marital Status				Select One
Spouse Business/Industry				Select One
Spouse Business (if "Other")
Spouse Occupation				Select One
Spouse Occupation (if "Other")
Spouse Highest Level of Education				Select One
Mailing Address
Residence Type
If Other Residence Type, explain

Street Address

Street Address (Line 2)

ZIP

Additional Auto Policy Information
All vehicles garaged at mailing address?				Yes No
Auto Reason for Policy
Any reportable Accidents/Major Violations/Comp Claims within the past 5 years or minor violations in 3 years?				Yes No
Any reportable Accidents/Comp Claims/Violations within 3 years?				Yes No
Any reportable Accidents/Comp Claims within the past 5 years or any violations in 3 years?				Yes No
Any reportable Accidents/Comp Claims/Minor Violations within 3 years or Major Violations in the past 10 years?				Yes No
Auto Additional Interests?				Yes No
Advanced Multiple Car Discount
Named Non-Owner
Authorization to use Credit Score?				Yes No
Is Driving Record Verifiable?				Yes No
Longevity Credit Date
Accident Free Credit Date
Do you want this quoted for an annual term if available? (Please note: Choosing a 12 month term could result in a higher premium quoted.)				Yes No
Additional Home Policy Information
Home Policy Form (click for definitions)
Is the location address the same as the mailing address?				Yes No
Reason location address is different
Explain reason location address is different

Location Address

Time at Present Address - Years
Time at Present Address - Months

Personal App: Home Underwriting
HomePolicyForm				HO-2 - Broad Form
Mortgagee?
Additional Insured
Additional Insured Student Living A way from Residence Premises
Additional Residences Premises
Additional Residence Premises Rented
Assisted Living Care Coverage
Is the home under construction?				Yes No
Is the dwelling or any unit in the dwelling vacant (not occupied by tenants)?				Yes No
Number of rental units owned by the applicant (including this location)?
Number of Years Property Owned
Number of Months Property Owned
Is Dwelling For Sale?				Yes No
Is there a business on the premises?				Yes No
Choose type of business
Is this the applciants primary business?				Yes No
Business Address

Is there a swimming pool?				Yes No
Is swimming pool fenced?				Yes No
Is there a dog on the premises?				Yes No
Does the insured have any of the following pets? Pit Bull, Rottweiler, Doberman, Chow Chow, exotic pet, or a pet with a prior bite history				Yes No
Any dog on the premises with a bite history?				Yes No
Is there a woodburning stove on the premises?				Yes No
Is there a solid fuel appliance (food, coal or pellet) on premises?				Yes No
Are horses and/or livestock kept on the premises?				Yes No
Stables Size
Is there a trampoline on the premises				Yes No
Is residence exclusively held for rental?				Yes No
Is dwelling owner unoccupied for more than 8 consecutive weeks?				Yes No
Number of weeks owner unoccupied?
Is dwelling sublet or rented when owner unoccupied?
Current or most recent property insurance carrier?
Carrier Name (if not in list)
Reason no previous property insurance?
Explain reason no previous property insurance

Prior Effective Date
Prior Expiration Date
Prior Policy Number
Prior Premium
Has property insurance been cancelled, declined or non-renewed in the last 5 years?				Yes No
Reason property insurance was cancelled, declined or non-renewed?
Explain other reason property insurance was cancelled, declined or non-renewed?

Any losses incurred in the last 5 years to the insured's home or personal possessions at this or another location?				Yes No
Does insured qualify for multi-policy credit?				Yes No
Choose Carrier
Policy type
Policy Number
Is this a secondary dwelling?				Yes No
Primary Policy #
# of People Employed Full Time (Gardener, Housekeeper, Nanny, etc.)?
Inside City Limits?				Yes No

Personal App: Home Underwriting
HomePolicyForm				HO-2 - Broad Form
Mortgagee?
Additional Insured
Additional Insured Student Living A way from Residence Premises
Additional Residences Premises
Additional Residence Premises Rented
Assisted Living Care Coverage
Is the home under construction?				Yes No
Is the dwelling or any unit in the dwelling vacant (not occupied by tenants)?				Yes No
Number of rental units owned by the applicant (including this location)?
Number of Years Property Owned
Number of Months Property Owned
Is Dwelling For Sale?				Yes No
Is there a business on the premises?				Yes No
Choose type of business
Is this the applciants primary business?				Yes No
Business Address

Is there a swimming pool?				Yes No
Is swimming pool fenced?				Yes No
Is there a dog on the premises?				Yes No
Does the insured have any of the following pets? Pit Bull, Rottweiler, Doberman, Chow Chow, exotic pet, or a pet with a prior bite history				Yes No
Any dog on the premises with a bite history?				Yes No
Is there a woodburning stove on the premises?				Yes No
Is there a solid fuel appliance (food, coal or pellet) on premises?				Yes No
Are horses and/or livestock kept on the premises?				Yes No
Stables Size
Is there a trampoline on the premises				Yes No
Is residence exclusively held for rental?